activity scheduling for depression in older adults
March 2013 (updated May 2015) E LDER C ARE A Resource for Interprofessional Providers Activity Scheduling for Depression in Older
Services Task Force recommends screening adults for depression when resources are in place to assure accurate diagnosis, treatment, and follow-up. The American Geriatrics Society also supports depression screening for older adults in primary care settings.
Table 1. Examples of “Activity Scheduling” Activities Associated with Improvements in Depression Exercise Ranging from vigorous physical exercise to less-vigorous activities like walking, gardening, or yoga Less-Active Physical Activities
Encourage active participation from patients, including tracking activities and consistent reassessment of which activitiesimprove their mood.
Use a validated tool, like the PHQ-9 or GDS, to assess baseline depression and monitor depression severity throughout treatment.
Use AS as part of an interprofessional approach to late-life depression treatment. Include a care manager when possible and a psychiatrist for refractory cases of depression.
TIPS for Incorporating Activity Scheduling (AS) into Primary Care Treatment of Depression
Several tools are available for depression screening. The 9-item Patient Health Questionnaire (PHQ-9) is well- validated for use in geriatric populations. The questionnaire takes just a few minutes to administer, can be self-administered, and is available at no cost. Another option is the Geriatric Depression Scale (GDS), a well- validated instrument for which a short form is also available. Both instruments can be easily located with an Internet search.
Step 1 Diagnosing Depression The U.S. Preventive
Most older adults with depression initially present to a primary care clinician and up to 10% of the older adults seen in primary care practice are affected by depression. Many factors can influence the severity of depression, one of which is social isolation. Addressing social isolation can improve outcomes for older adults who have depression.
Incorporation of activity scheduling into clinical practice involves five steps: diagnosis, discussion, homework, motivation, and reassessment.
Incorporating Activity Scheduling Into Practice
Indeed, in an analysis of behavioral management in the recent Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) program, it was shown that a wide variety of activities can be effective, and not all of these activities need to be considered “pleasant” activities in the typical sense. Nonetheless, participation in any of them (Table 1) can improve depression outcomes. Even activities such as organizing medications and reflecting on symptom improvement related to medications may reduce stress and lessen symptoms of depression.
AS can take many forms in depression treatment, but the goal is the same - to increase contact with the environment in a positively reinforcing way. Traditionally, AS involves scheduling “pleasant” activities, defined as activities that are pleasurable to patients and which elevate their mood. However, any activity that includes the intention to socialize is associated with better depression outcomes.
Activity scheduling (AS) is an effective behavioral treatment that addresses social isolation in patients with depression. It is an approach that actively involves patients by increasing the number of daily activities in which they participate. Activity scheduling is an established core component of evidence-based depression treatment that has been shown to be just as effective as other forms of cognitive behavioral therapy (CBT). Research shows a strong association between AS and both self-reported activities and depression improvement over the course of 12 months.
Shopping, baking, attending community events, arts and crafts, singing in a choir, lunch with friends or family Passive Activities Television, radio, looking at photos, writing in a journal Medication Management Organizing medications; reflecting on symptom improvement after starting medications www.aging.arizona.edu Continued from front page
Step 2 Discuss Activities Once the diagnosis of depression AS can also be an adjunct to treatment of individuals
has been confirmed and the patient is felt to be stable whose depression has led them to feel suicidal. These indi- (e.g., not suicidal or needing psychiatric hospitalization), AS viduals may see their lives as having no meaning or pur- is initiated by discussing with patients the various activities pose. Giving them activities that engage them in life can in which they currently participate, activities they enjoy or help alleviate profound depression and focus their thoughts think they might enjoy, and activities in which it is realistic on constructive activities.
Activity Scheduling and Interprofessional Care
for them to participate. These activities can range from traditional pleasurable activities to others, such as those The best late-life depression outcomes come from a collab- shown in Table 1. orative, interprofessional approach to treatment. While
Step 3 Give the Patient Homework Patients should be as- activity scheduling is a core component of such an ap- signed the task of scheduling and completing the selected proach, it should not be viewed as an isolated treatment.
activities. Scheduling can be as strict as having a daily cal- Pharmacotherapy, other forms of psychological counseling, endar that details a specific time for each activity (Table social service support when needed, and physical therapy (especially for individuals who have become home bound)
2). Or, it can be a more relaxed approach of simply jot- are all part of what constitutes good depression care. ting activities down in a planner or even making a mental
Although not all clinical facilities have the personnel and note of the activities that need to occur. Either way, the infrastructure needed to institute a wide variety of effec- point is for the patient to actually complete the activities. tive interprofessional treatments for depression, individual
There is a strong association between discussing and plan- clinicians can still include AS as one component of the treat- ning activities and self-reported activity engagement at 12 ment they provide to older adults with depression. months, lending support to the importance of working with patients to generate an activity plan.
Table 2. Sample Activity Scheduling Calendar Step 4 Motivate and Encourage AS often means a change
Time Mon Tues Weds
in individual daily routines. Changing routines is best done in supportive environments.
7-8 am Breakfast Breakfast Breakfast Step 5 Reassess Depression severity should be reassessed
8-9 am Call daughter Meet Fran Balance checkbook
at intervals, using instruments such as the PHQ-9 or GDS
9-10 am Go for walk With Fran in park Go for walk
that were used at the time of diagnosis. Comparison of
10-11 am Therapy apt Food shopping Write letter to son
PHQ-9 or GDS scores to scores at the time of diagnosis can help determine if depression is improving. Depending on
11 am - noon Lunch w/Sal Lunch Lunch
the patient’s progress, changing or adding activities may be
noon-2 pm Reading time Reading time Reading time
appropriate, as might additional therapeutic measures in-
2-3 pm Piano Piano Dr appointment
cluding modifying medication regimens or using other be- havioral interventions.
3-4 pm Garden work Computer class Dr appointment Who are the Best Candidates for Activity Scheduling?
4-5 pm Garden work Computer class Dr appointment
AS is appropriate for a variety of older adults who suffer
6-8 pm Cook and eat Cook and eat Cook and eat
from depression. There is particular benefit for individuals who spend long periods of time in bed, who are physically
8-9 pm Watch TV Watch TV Watch TV inactive, or who have been avoiding family and friends.
References and Resources
Arean P, Hegel M, Vannoy S, Fan M, Unützer, J. Effectiveness of problem solving therapy for older, primary care patients with depression: Results from the IMPACT project.
Gerontologist. 2008;48(3): 311-323.
Cuijpers P, van Straten A, Warmerdam L. Behavioral activation treatments of depression. Clin Psych Rev. 2007;27: 318-326. Kanter J, Manos R, Bowe W, et al What is behavioral activation? A review of the empirical literature. Clin Psych Rev. 2010;30:608-620. Riebe G, Fan M, Unützer, J, Vannoy S. Activity Scheduling as a core-component of effective care management for late-life depression. Int J Geriatr Psych. 2012;27: 1298- 1304.
San Francisco Bay Area Center for Cognitive Therapy. Activity scheduling for depressed clients. Am J Epidemiol. 2002;156: 328-334.
Interprofessional care improves the outcomes of older adults with complex health problems
Editors: Mindy Fain, MD; Jane Mohler, NP-c, MPH, PhD; and Barry D. Weiss, MD
Interprofessional Associate Editors: Tracy Carroll, PT, CHT, MPH; David Coon, PhD; Jeannie Lee, PharmD, BCPS;
Lisa O’Neill, MPH; Floribella Redondo; Laura Vitkus, BA
The University of Arizona, PO Box 245069, Tucson, AZ 85724-5069 | (520) 626-5800 | http://aging.medicine.arizona.edu
Supported by: Donald W. Reynolds Foundation, Arizona Geriatric Education Center and Arizona Center on Aging
This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS)
under grant number UB4HP19047, Arizona Geriatric Education Center. This information or content and conclusions are those of the author and shouldnot be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.